Isabel T. Lagomasino

Depression, Correlates of Depression, and Receipt of Depression Care Among Low-Income Women With Breast or Gynecologic Cancer

PURPOSE To assess the prevalence of depression among low-income, ethnic minority women with breast or gynecologic cancer, receipt of antidepressant medications or counseling services, and correlates of depression. PATIENTS AND METHODS Study patients were 472 women receiving cancer care in an urban public medical center. Women had a primary diagnosis of breast (stage 0 to III) or gynecologic cancer (International Federation of Gynecology and Obstetrics stage 0 to IIIB). A diagnostic depression screen and baseline questionnaire were administered before or during active treatment or during active follow-up. Self-report data were collected on receipt of depression treatment, use of supportive counseling, pain and receipt of pain medication, functional status and well-being, and perceived barriers to cancer care. RESULTS Twenty-four percent of women reported moderate to severe levels of depressive disorder (30% of breast cancer patients and 17% of gynecologic cancer patients). Only 12% of women meeting criteria for major depression reported currently receiving medications for depression, and only 5% of women reported seeing a counselor or participating in a cancer support group. Neither cancer stage nor treatment status was correlated with depression. Primary diagnosis of breast cancer, younger age, greater functional impairment, poorer social and family well-being, anxiety, comorbid arthritis, and fears about treatment side effects were correlated with depression. CONCLUSION Findings indicate that depressive disorder among ethnic minority, low-income women with breast or gynecologic cancer is prevalent and is correlated with pain, anxiety, and health-related quality of life. Because these women are unlikely to receive depression treatment or supportive counseling, there is a need for routine screening, evaluation, and treatment in this population.

Improving Care for Minorities: Can Quality Improvement Interventions Improve Care and Outcomes For Depressed Minorities? Results of a Randomized, Controlled Trial

OBJECTIVE Ethnic minority patients often receive poorer quality care and have worse outcomes than white patients, yet practice-based approaches to reduce such disparities have not been identified. We determined whether practice-initiated quality improvement (QI) interventions for depressed primary care patients improve care across ethnic groups and reduce outcome disparities. STUDY SETTING The sample consists of 46 primary care practices in 6 U.S. managed care organizations; 181 clinicians; 398 Latinos, 93 African Americans, and 778 white patients with probable depressive disorder. STUDY DEIGN: Matched practices were randomized to usual care or one of two QI programs that trained local experts to educate clinicians; nurses to educate, assess, and follow-up with patients; and psychotherapists to conduct Cognitive Behavioral Therapy. Patients and physicians selected treatments. Interventions featured modest accommodations for minority patients (e.g., translations, cultural training for clinicians). DATA EXTRACTION METHODS Multilevel logistic regression analyses assessed intervention effects within and among ethnic groups. PRINCIPAL FINDINGS At baseline, all ethnic groups Latino, African American, white) had low to moderate rates of appropriate care and the interventions significantly improved appropriate care at six months (by 8-20 percentage points) within each ethnic group, with no significant difference in response by ethnic group. The interventions significantly decreased the likelihood that Latinos and African Americans would report probable depression at months 6 and 12; the white intervention sample did not differ from controls in reported probable depression at either follow-up. While the intervention significantly improved the rate of employment for whites and not for minorities, precision was low for comparing intervention response on this outcome. It is important to note that minorities remained less likely to have appropriate care and more likely to be depressed than white patients. CONCLUSIONS Implementation of quality improvement interventions that have modest accommodations for minority patients can improve quality of care for whites and underserved minorities alike, while minorities may be especially likely to benefit clinically. Further research needs to clarify whether employment benefits are limited to whites and if so, whether this represents a difference in opportunities. Quality improvement programs appear to improve quality of care without increasing disparities, and may offer an approach to reduce health disparities.

Racial and ethnic disparities in detection and treatment of depression and anxiety among psychiatric and primary health care visits, 1995-2005.

Context:Recent evidence questions whether formerly documented disparities in care for common mental disorders among African Americans and Hispanics still remain. Also, whether disparities exist mainly in psychiatric settings or primary health care settings is unknown. Objective:To comprehensively examine time trends in outpatient diagnosis and treatment of depression and anxiety among ethnic groups in primary care and psychiatric settings. Design and Setting:Analyses of office-based outpatient visits from the National Ambulatory Medical Care Study from 1995–2005 (n = 96,075). Participants:Visits to office-based primary care physicians and psychiatrists in the United States. Main Outcome Measures:Diagnosed with depression or anxiety, received counseling or a referral for counseling, received an antidepressant prescription, and any counseling or antidepressant care. Results:In these analyses of 10-year trends in treatment of common mental disorders, disparities in counseling/referrals for counseling, antidepressant medications, and any care vastly improved or were eliminated over time in psychiatric visits. Continued disparities in diagnoses, counseling/referrals for counseling, antidepressant medication, and any care are found in primary care visits. Conclusions:Disparities in care for depression and anxiety among African Americans and Hispanics remain in primary care. Quality improvement efforts are needed to address cultural and linguistic barriers to care.

Double-blind study of high-dose fluoxetine versus lithium or desipramine augmentation of fluoxetine in partial responders and nonresponders to fluoxetine.

In a previous study, of 41 depressed patients who had not responded to fluoxetine 20 mg/day, 53% were treated with high-dose fluoxetine (40–60 mg/ day) and responded (i.e., their 17-item Hamilton Rating Scale for Depression [HAM-D-17] score was <7) versus 29% and 25% of patients treated with fluoxetine plus lithium (300–600 mg/day) or fluoxetine plus desipramine (25–50 mg/day), respectively. We wanted to assess whether these findings could be replicated in a larger sample of depressed outpatients. We identified 101 outpatients with major depressive disorder (52 men and 49 women; mean age, 41.6 + 10.6 years) who were either partial responders (n = 49) or nonresponders (n = 52) to 8 weeks of treatment with fluoxetine 20 mg/ day. These patients were randomized to 4 weeks of double-blind treatment with high-dose fluoxetine (40–60 mg/day), fluoxetine plus lithium (300–600 mg/day), or fluoxetine plus desipramine (25–50 mg/day). In the overall group of patients (N = 101), there was no significant difference in response rates across the three treatment groups (high-dose fluoxetine, 42.4%; fluoxetine plus desipramine, 29.4%; fluoxetine plus lithium, 23.5%). Dropout rates were also comparable, ranging from 9.1% (high-dose fluoxetine) to 14.7% (fluoxetine plus desipramine and fluoxetine plus lithium). There were also no significant differences in response rates across the three treatment groups among partial responders (high-dose fluoxetine, 50.0%; fluoxetine plus desipramine, 33.3%; fluoxetine plus lithium, 33.3%) and nonresponders (high-dose fluoxetine, 35.3%; fluoxetine plus desipramine, 26.3%; fluoxetine plus lithium, 12.5%). At the end of the study, the mean lithium level was 0.37 + 0.15 mEq/L (n = 27; range, 0.1–0.8 mEq/L) among lithium-treated patients, and the mean desipramine level was 104.7 + 58.8 ng/mL (n = 22; range, 25–257 ng/mL). There were no significant relationships between lithium or desipramine blood levels and degree of improvement (as measured by the change in HAM-D-17 score). We found no significant differences in efficacy among these three treatment strategies among patients who had failed to respond adequately to 8 weeks of treatment with fluoxetine 20 mg/day, although the high-fluoxetine group was associated with nonsignificantly higher response rates in both partial responders and nonresponders.

Measuring Latinos’ Perceptions of Depression: A Confirmatory Factor Analysis of the Illness Perception Questionnaire

This study examined the psychometric properties of the Revised Illness Perception Questionnaire adapted for a clinical sample of low-income Latinos suffering from depression. Participants (N = 339) were recruited from public primary care centers. Their average age was 49.73 years and the majority was foreign born females of either Mexican or Central American descent. Confirmatory factor analysis was used to test the factor structure of this measure. Construct and discriminant validity and internal consistency were evaluated. After the elimination of three items because of low factor loadings (< .40) and the specification of seven error covariances, a revised model composed of 24 items had adequate goodness-of-fit indices and factor loadings, supporting construct validity. Each of the subscales reported satisfactory internal consistency. Intercorrelations between the 5 illness perception factors provided initial support for the discriminant validity of these factors in the context of depression. The establishment of the psychometric properties of this adapted measure will pave the way for future studies examining the role illness perceptions play in the help seeking and management of depression among Latinos.

Management of major depression in the primary care setting

Background: Patients treated in community clinics, particularly those of minority status, may rely more heavily on primary care physicians (PCPs) for the diagnosis and management of depression. We wished to determine how PCPs in a community clinic setting initially manage patients newly diagnosed with major depression. Methods: 698 patients were screened for major depression by the Structural Clinical Interview for DSM-III-R in a community-based primary care health center. Forty outpatients (29 Hispanic) were found to suffer from major depression. A letter explaining positive findings was sent to the patients’ PCPs. Medical record charts were reviewed 3 months later to determine the PCP’s management following the diagnosis. Results: Of the 38 patients who remained in the study at 3 months, 20 (53%) received no intervention from the PCP by the end of 3 months after diagnosis, and of these, 14 were Hispanic. Five (13%) were prescribed an antidepressant by the PCP. Nine (24%) were referred to mental health services for medication, psychotherapy or combination treatment. Four (11%) were prescribed an antidepressant and then referred to mental health services. Differences between management of Hispanic and non-Hispanic patients were not statistically significant. Conclusions: Independent screening by psychiatrists in primary care settings may not be adequate enough to ensure appropriate management of depression by PCPs. Possible explanations may include time constraints during primary care visits, patient and/or physician reticence, and insufficient education of PCPs about depression.

MEDICAL ASSESSMENT OF PATIENTS PRESENTING WITH PSYCHIATRIC SYMPTOMS IN THE EMERGENCY SETTING

Psychiatrists in the emergency department (ED) are often asked to evaluate patients with disturbances of affect, behavior, and cognition. The first and most crucial step in the evaluation process is to eliminate possible medical causes for a patient presenting psychiatric symptoms. Failure to detect and diagnose underlying medical disorders may result in significant and unnecessary morbidity and mortality.

Characteristics of women receiving mandated treatment for alcohol or polysubstance dependence in Massachusetts.

Characteristics of the first 20 women consecutively admitted for treatment for alcohol or polysubstance dependence following civil commitment by Massachusetts courts were studied. Women were diagnosed as either alcohol dependent (n = 12) or polysubstance dependent (n = 8). Alcohol dependent women were older at initial alcohol use, onset of regular alcoholic use, first treatment admission, and at this admission. For the group as a whole 75% had completed high school; 50% were divorced and 35% were supported by public assistance. Seventy-five percent had a family history of alcoholism. This sample of women who received court-ordered alcohol and polysubstance dependence treatment had multiple social, psychological, legal and health problems.

Efficiency in mental health practice and research

Limited financial resources, escalating mental health-related costs and opportunities for capitalizing on advances in health information technologies have brought the theme of efficiency to the forefront of mental health services research and clinical practice. In this introductory article to the journal series stemming from the 20th NIMH Mental Health Services Research Conference, we first delineate the need for a new focus on efficiency in both research and clinical practice. Second, we provide preliminary definitions of efficiency for the field and discuss issues related to measurement. Finally, we explore the interface between efficiency in mental health services research and practice and the NIMH strategic objectives of developing improved interventions for diverse populations and enhancing the public health impact of research. Case examples illustrate how perspectives from dissemination and implementation research may be used to maximize efficiencies in the development and implementation of new service delivery models. Allowing findings from the dissemination and implementation field to permeate and inform clinical practice and research may facilitate more efficient development of interventions and enhance the public health impact of research.

Effectiveness of Collaborative Care for Depression in Public-Sector Primary Care Clinics Serving Latinos

OBJECTIVE Quality improvement interventions for depression care have been shown to be effective for improving quality of care and depression outcomes in settings with primarily insured patients. The aim of this study was to determine the impact of a collaborative care intervention for depression that was tailored for low-income Latino patients seen in public-sector clinics. METHODS A total of 400 depressed patients from three public-sector primary care clinics were enrolled in a randomized controlled trial of a tailored collaborative care intervention versus enhanced usual care. Social workers without previous mental health experience served as depression care specialists for the intervention patients (N=196). Depending on patient preference, they delivered a cognitive-behavioral therapy (CBT) intervention or facilitated antidepressant medication given by primary care providers or both. In enhanced usual care, patients (N=204) received a pamphlet about depression, a letter for their primary care provider stating that they had a positive depression screen, and a list of local mental health resources. Intent-to-treat analyses examined clinical and process-of-care outcomes at 16 weeks. RESULTS Compared with patients in the enhanced usual care group, patients in the intervention group had significantly improved depression, quality of life, and satisfaction outcomes (p<.001 for all). Intervention patients also had significantly improved quality-of-care indicators, including the proportion of patients receiving either psychotherapy or antidepressant medication (77% versus 21%, p<.001). CONCLUSIONS Collaborative care for depression can greatly improve care and outcomes in public-sector clinics. Social workers without prior mental health experience can effectively provide CBT and manage depression care.